This is part of a series of stories about people working on solutions to New Hampshire's maternity care challenges. Catch up on more of our coverage here.
On a recent morning at Androscoggin Valley Hospital’s labor and delivery unit in Berlin, nurses are checking in on a patient. Noelle, who’s 32, was induced 39 weeks into her pregnancy. When her water doesn’t break, the doctor decides to artificially rupture the membranes.
Within minutes, her baby’s heartbeat starts dropping.
A nurse checks Noelle’s cervix and finds the cause: The umbilical cord is coming out before the baby. It’s a dangerous condition known as a prolapsed cord. It can choke off the flow of blood and oxygen to the baby. Noelle needs a C-section immediately.
An urgent alert — “Code C” — sounds from the intercom as they wheel Noelle toward the operating room. The whole way down the hall, one of the nurses carefully holds up the baby’s head, so it doesn’t constrict the cord.
A minute later, they’re in the operating room, joined by a doctor who’s ready to start Noelle’s C-section.
Or who would be — if Noelle were a real patient. She’s actually a pregnant mannequin, used to train hospital staff to be ready for obstetric emergencies. Her stomach snaps open to reveal a fake baby inside.
As a small facility in New Hampshire’s most rural region, Androscoggin Valley Hospital delivers about 70 babies a year. (By comparison, the Elliot Hospital in Manchester reports about 2,000 deliveries annually.)
But even in quieter maternity wards, providers have to be ready for anything – which is the reason for today’s drill. It’s part of a bigger effort to fill gaps in a maternity care system that’s been eroding for years.
“Our care of the pregnant patients in this community is super important,” said Natalie Valliere, the nurse who runs the labor and delivery unit at Androscoggin Valley Hospital. “Because otherwise they would have to travel an hour plus to get just even basic prenatal care – their monthly check-ins and fetal heart rate checks and measurements.”
Coos County used to have three hospitals delivering babies. Now, Androscoggin Valley Hospital is the only one.
It’s a reality across many rural areas in New Hampshire. Facing financial challenges and declining births, more than half of the state’s rural hospitals have closed their labor and delivery units in the last 25 years.
More than a quarter of patients now live a half hour or more from the nearest birthing hospital – making it harder to access routine prenatal care and raising the risk of an unplanned birth at home or on the way to the hospital, according to a 2021 Urban Institute study.
Rural hospitals like Androscoggin Valley Hospital are also more dependent on Medicaid to cover births, which adds to the financial challenges of running a labor and delivery unit because its reimbursement rates are lower.
“Access to the full range of obstetric services just isn't there in the rural areas as much as it used to be,” said David Laflamme, a maternal and child health epidemiologist who’s working with the North Country effort.
Valliere and others working on this issue in the North Country say there’s no single answer. But in a region where people and resources are spread out over a vast rural area, they say collaboration will be key.
That’s the idea behind the North Country Maternity Network – a nascent effort to improve access to care in the region, supported by a four-year federal grant managed by Dartmouth Health. It’s a collaboration between hospitals, health workers, social service nonprofits and others.
“If you were having a heart attack, would you want to have to drive three hours to receive medical care?” said Ali Willard, a high-risk obstetrics nurse and care coordinator with Dartmouth Health. “No. And that's not a standard anywhere in our country to have to drive that far for that type of emergency. But obstetric emergencies are just as critical to somebody's life. But some women have to drive that far.”
Part of Willard’s role is to help patients in the North Country who need a higher level of care than what’s available locally. She helps coordinate that care with specialists at Dartmouth-Hitchcock Medical Center.
Sometimes, they’re able to do follow-up appointments via telehealth, or order tests to be done locally in Berlin with the results sent to Dartmouth – so patients don’t have to make the two- or three-hour drive to Lebanon each time.
Willard said the local community health center, Coos County Family Health Services, is working on making it possible for patients to do those telehealth appointments at its clinics, because some people don’t have internet access.
"It's not just about the few people that might be having a baby here. It's like that future potential. Are we going to be able to grow in the North Country?”Rebecca Hill-Larsen, North Country Health Consortium
Efforts are also underway to give EMTs and ER doctors in the region more training on how to respond to obstetric emergencies, in case something happens far from the nearest birthing hospital.
“We shouldn't have to live in an urban area to receive the highest level of evidence-based care,” Willard said.
In an area with one of the state’s highest poverty rates, some patients also struggle with food insecurity, homelessness and other challenges during pregnancy.
The Littleton-based North Country Health Consortium is trying to help patients meet those basic needs by hiring several doulas who are also trained as community health workers. Along with providing pregnancy-related support and guidance, they can help patients navigate insurance or find housing.
Rebecca Hill-Larsen, who oversees the program, said one of the biggest issues is that many people don’t have reliable transportation. She recalled how one of their doulas was working with a pregnant client who got into a car accident. When doctors asked her to come in for a checkup afterward, she said she didn’t have a way to get there.
As they work to strengthen maternity care in the North Country, Hill-Larsen and others say that mission is about more than supporting parents and newborns. It’s about whether communities here can survive and thrive.
“If you don't see yourself being able to move to a place and have a baby and raise your family, are you going to choose to move to that place?” she said. “So it's not just about the few people that might be having a baby here. It's like that future potential. Are we going to be able to grow in the North Country?”
